Provider Demographics
NPI:1861569113
Name:LATHAM, DARLA K (OD)
Entity type:Individual
Prefix:DR
First Name:DARLA
Middle Name:K
Last Name:LATHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3206
Mailing Address - Country:US
Mailing Address - Phone:336-768-9262
Mailing Address - Fax:336-768-4481
Practice Address - Street 1:1010 S STRATFORD RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3206
Practice Address - Country:US
Practice Address - Phone:336-768-9262
Practice Address - Fax:336-768-4481
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-659 TA-352152W00000X
NC1353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU01821Medicare UPIN
AL58104Medicare ID - Type Unspecified